If a patient has a fragility fracture but a normal T-score on DXA, how should you proceed?

• A. Do nothing until T-score drops
• B. Reassess only after another fracture occurs
• C. Evaluate for secondary causes of bone loss, treat osteoporosis based on fracture history, and assess for vertebral fractures
• D. Stop all osteoporosis therapy

Answer: (C)

A fragility fracture indicates substantial skeletal weakness even when the DXA T-score is normal. Bone density is only part of the picture; a fracture shows that bone quality and structure have already failed under minimal trauma, so treatment decisions should be guided by fracture history, not by T-score alone.

Therefore, the appropriate approach is to look for secondary causes of bone loss that might be driving fragility, start osteoporosis treatment based on the fracture history to reduce future fracture risk, and check for vertebral fractures since many can be hidden and still influence management. Vertebral fracture assessment or spine imaging helps identify prevalent fractures that may prompt more aggressive therapy.

Doing nothing or waiting for the T-score to worsen would miss a chance to prevent another fracture. Stopping therapy would be inappropriate given the prior fragility fracture.